This sentiment was prompted by a Florida pediatrician that refused to continue seeing a child after the parents refused to answer whether they kept firearms in the home. Governor Rick Scott (FL) signed HB-155 into law this month. The law restricts physicians from asking families if they have firearms, prohibits them from discussing firearm safety with families and prohibits them from documenting firearm status in a medical chart.

The physician-patient relationship is predicated on trust. There must be trust that a patient is being truthful when answering questions. There must also be trust, on a patient’s part, that a physician role is to empower patients to make informed decisions that will ultimately lead to better health.

Last month, in my allergy/immunology practice, a patient presented with acute onset of hives that morning. While hives is not unusual in my office, her presentation seemed odd to me. I asked her about life stress and she answered that she was under some stress but didn’t want to go into details. I then proceeded to ask her about what medications she may have tried to help with the hives. She casually mentioned that her primary care physician had given her a prescription for oral steroids that morning. I was surprised to know that she had seen him just three hours before her arrival in my office and asked how this could be. She then began to retell the events of the past 12 hours. She said that 12 hours prior she had been drinking wine and had drank a bit too much and her husband found her unresponsive. She was transported to the ER and had her stomach ‘pumped’. She was then admitted for observation and her primary care doctor discharged her in the morning after advising her to be more careful when drinking.

I found this story concerning for many reasons. She seemed anxious and tearful. I then asked her if she had tried to kill herself. To my surprise, she answered ‘Yes’. I asked her if she had any intention to harm herself or if she owned a gun. She said ‘Yes’.

Her husband spoke to me in private and recalled that not one health care provider, from EMT to ER nurse, to ER doctor to admitting physician to her own primary care doctor asked her these questions. I don’t know why no one else asked – maybe they were too busy; maybe they didn’t identify the unusual circumstances; or maybe they were afraid that the patient would feel they were making a moral judgment. I simply did what seemed natural. I listened to my patient and I heard a cry for help.

My patient was then escorted to the psychiatric ER for evaluation and treatment. She has since thanked me for taking the time to listen and for having the courage to ask her that simple question. She did not feel that my questions were thinly veiled moral judgments. She recognized that my intent was to help her.

I fear that HB 155 will further stifle this sort of honest communication. The law will cause many providers to take pause before asking difficult questions that impact patient’s lives. The law sets a precedent. As an allergist, I always ask my patients if they smoke and I ask parents of asthmatic children if they smoke. I don’t ask to pass moral judgment. I ask so we can have a dialogue. Parents need to understand that by smoking, their children have an increased risk of developing asthma.

In the course of a patient evaluation, I often ask if my patient has a tattoo or if they have ever used intravenous drugs or if the have ever engaged in high risk sexual activities. I ask these, sometimes uncomfortable, questions not to pass moral judgment but to help guide me when diagnosing and treating patients. And I use this conversation as an opportunity to educate and counsel patients on choices that may help to keep them healthier and safer. When will this line of questioning become illegal? HB 155 places us at the top of a very slippery slope.

This law will hurt Florida’s children and further degrade a fragile physician-patient relationship. I am hopeful that the combined outrage of Florida physicians will be heard by our legislators.

Mona Mangat is an internal medicine-pediatrics physician who blogs at Progress Notes.

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Docs vs Glocks, and the slippery slope of HB 155 39 comments

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Jeff Taylor

Turning the medical question around, the gun nuts should ask if their physicians should not practice holistic medicine.

ninguem

The “gun nuts” were provoked in this case, with medical organizations pushing an anti-gun agenda on physicians and patients.

Jeff Taylor

Guns have been a big public health problem for many years. There’s no new agenda.

ninguem

Thank you for proving my point.

ErnieG

To expand: it is one thing for physicians to inquire about risk factors for accidental death in the course of a private medical interview. The issue is about an individual patient and their safety. And one does not need to be an expert in gun safety to advise an individual in broad terms so seek appropriate education about gun safety and give resources to pursue that.
It is quite another issue for medical organizations to push for stricter gun laws/gun control, an issue that has more to do with political rights.
Nevertheless, the law banning inquiry into gun ownership is wrong. For an organization that claims to protect constitutional rights, its pretty good at stifling free speach.

ninguem

Thank you. Government…….and our “professional” organizations (rapidly turning into political mouthpieces)…….have no business mandating the details of safety conversations.

The pro-gun organizations have nosed into this, because the anti-gun organizations nosed into this.

BOTH SIDES, get the hell out.

Leave me alone with my patient.

Thank you.

pj

Not saying this is the best way to do it, but the contrarian in me chuckles at this law. I see it as pushback against one of the issues we PCP’s complain about- we’re expected to cover too many bases in too little time.

Well, now at least we overworked PCP’s can have a bit more time by asking one less question!

JN

Unfortunately there is no non-agenda driven research (anything sponsored by the Joyce Foundation is suspect) that shows a connection between firearms ownership and injury to the owner or their families. Further, doctors are not experts on firearms safety or handling and are not qualified to dispense such advice.

Fortunately, the CDC collects and reports the data you are looking for. From the MMWR on May 13, 2011 / 60(18);573-578:

“During 2006–2007, a total of 25,423 firearm homicides and 34,235 firearm suicides occurred among U.S. residents. These national totals include 4,166 firearm homicides and 1,446 firearm suicides among youths aged 10–19 years; the rate of firearm homicides among youths slightly exceeded the rate among persons of all ages….

“During 2006–2007, firearm suicide and firearm homicide were the fourth and fifth leading causes of injury death in the United States, respectively . For youths aged 10–19 years, firearm homicide was the second leading cause and firearm suicide was the fifth leading cause of injury death nationally.”

They do not comment on gun ownership, but given that accessibility is a major factor in gun-related injury, I’m willing to infer that parents or close family friends were the owners in the majority of cases.

You’re right that doctors are not experts on firearm safety. However, the numbers quoted above show that firearms are a major public health hazard, and doctors should know more than the average bear about public health. This is not an “anti-gun” agenda but rather a “pro-safety” agenda.

The pediatrician is well within his sphere to ask about gun safety — he is trying to minimize risk to the child, the same way he would encourage the parents not to smoke, to put their baby on its back to sleep, to use carseats and seatbelts, etc. I am relieved that the Florida law makes an exception for this, but I’m with Dr. Mangat that we may be on the edge of a very slippery slope.

“The physician-patient relationship is predicated on trust. There must be trust that a patient is being truthful when answering questions.”

Yes, it is.

And the flip side of that coin is that patients may be reluctant to share personal information such as the particulars of firearms ownership, when that information is copied to a questionnaire from an organization as unapologetically anti-gun as the AAP.

And forgive me, but I know and respect a great many physicians, and very few of them know beans about firearms safety, other than the party line of trigger locks and keeping your weapons unloaded and ammunition stored separately, which is absolutely unworkable from a self-defense standpoint.

So the trust issue works both ways.

Perhaps if a pediatrician, when asking those questions, would offer advice and resources for safe gun handling, such as an approved firearms safety course (the NRA has an excellent one tailored specifically for children), rather than parrot the mantra of “GUNS ARE BAD! RUN AWAY!” used by so many of your colleagues, it would be easier for patients to trust their doctors with that sort of personal information.

All that said, I do agree with you that HB 155 is a bad idea. Much like JCAHO, who excels at finding needlessly complex solutions to nonexistent problems, HB 155 introduces the heavy hand of government to address an issue that could be handled with a polite but firm, “None of your business.”

Doctors should be free to ask whatever questions they deem relevant to the health and welfare of their patient. Patients should be able to trust their doctor with the answers to those sensitive questions, and be secure that the information they provide is not going to be used for data mining by a larger organization to advance a political agenda.

The problem here is that the doctor refused to treat a patient whose parents refused to answer questions they regarded as intrusive into their privacy, which is absolutely their right. Something has to be done to protect patients and parents in a situation like this where a doctor is overstepping his bounds.

While it sounds reasonable, in the interest of “safety,” to allow doctors to ask kids questions about conditions in their homes that might in theory jeopardize their safety, the reality is that kids are not very reliable witnesses, nor are physicians necessarily qualified to give advice based on the answers they receive. Parents have valid concerns that responses given by their children may not accurately reflect reality and my be blown out of proportion by a doctor misinterpreting the information received or even pursuing a hidden agenda. Additionally, they may not want information about gun ownership in their medical records where it may be used to deny insurance or be scrutinized by the government.

There was recently a discussion of the Hippocratic Oath here, which emphasizes the need to protect patient privacy and not reveal things that are heard in the course of medical practice, as well as implying that physicians should not practice outside their specialty. Doctors are generally not specialists in firearm safety.

From my own experience with being questioned on personal matters as an adult by physicians, I will never answer questions not directly related to my medical care again. In almost every case, innocuous answers to what I though were innocuous questions were distorted into something that either psychopathologized me or made me out to be untrustworthy.

Pointing out that I sometimes spend time on the computer and sometimes do research on my medical problems became: “Patient spends all day on the computer researching medical issues” in my chart. Reporting that I quit drinking over 20 years ago because drinking beer after work demotivated me from studying and because it seemed like a good idea for my health became “Patient has a history of alcohol abuse” and “patient quit drinking in college because his drinking was out of control.”

Doctors should focus on the patient’s medical care, and leave child safety to the experts. It may be excessive to deny doctors the right to question patients altogether, but if we give them carte blanche, where do we draw the line on invasions of privacy? Anything can be justified in the name of “safety” including asking deeply intimate questions about your child’s sexual activities or inclinations.

Kristin

“While it sounds reasonable, in the interest of ‘safety,’ to allow doctors to ask kids questions about conditions in their homes that might in theory jeopardize their safety, the reality is that kids are not very reliable witnesses, nor are physicians necessarily qualified to give advice based on the answers they receive. Parents have valid concerns that responses given by their children may not accurately reflect reality and my be blown out of proportion by a doctor misinterpreting the information received or even pursuing a hidden agenda. Additionally, they may not want information about gun ownership in their medical records where it may be used to deny insurance or be scrutinized by the government.”

You could replace every reference here to guns with a reference to child abuse.

Let me be perfectly clear: I am not saying that owning a gun is tantamount to child abuse. What I am saying is that this specific argument is logically flawed.

Children are not reliable witnesses. But we listen to them anyway, because children will tell us things that parents won’t, and because it’s never safe to assume that they’re mistaken or lying. Not every spanking is child abuse, but some are; not every gun owner is unsafe, but some are. And in both cases, we need to be concerned. In both cases, it’s better to overreact–to start a conversation with the parents about what they do and why, even to call in the authorities–and inconvenience the parents than to underreact, and risk a child’s safety.

Bad people, and bad parents, need doctors too; they see doctors, sometimes they even take their kids to doctors. And that’s when it falls to doctors to step out of their regular roles and into these uncomfortable and unfamiliar conversations.

Every argument you make could also be made about the police, or any other area of safety concern. Should the police be able to randomly search your kid for drugs or guns? Should they be allowed to interrogate the children of doctors who are known to keep closets full of potentially lethal free drug samples in their homes? The Constitution affords us protection against unreasonable search and seizure for a reason. Additionally, there are other laws that protect privacy at the state and Federal level. Public safety is always the excuse of choice for reducing civil liberties. Is there ever another excuse offered for doing so?

The police are required to obtain a warrant or have “probable cause” to violate these civil rights. Should persons unqualified in law or public safety be able to use children as a means of skirting around these protections? Note that the law in question does allow doctors to ask questions about guns where the doctor feels there is what amounts to “probable cause” to think guns might pose a safety issue to the patient. Here’s a good example of why parents have legitimate concerns about the kind of information being dragged out of their kids:

It’s difficult to see how merely questioning a child is going to lead to a reduction in the murder or suicide rate unless you use that child’s responses to seize weapons in the home, which means involving law enforcement. If the goal is to educate parents rather than seizing firearms, than that can be better accomplished by handing parents booklets about firearms and other safety concerns, and leave the limited time available in a doctor’s visit for discussion of medical problems. Let’s not forget the staggering death and injury rate from medical care in this country, which can only be exacerbated by bogging down doctors with too many responsibilities which distract the physician from the medical problems at hand. Medical societies should focus on improving safety under their own roofs, not any one else’s.

This article is a little off. I know this doctor in Ocala, FL and he didn’t stop seeing them because they refused to answer. He finished the visit and later dismissed them from the practice because they were belligerent, threatening, and disruptive to his office. The questions are not the problem–the intent is. As a gynecologist who sees adolescents, I often ask “deeply intimate questions about your child’s sexual activties or inclinations.” Personally, I’d rather not know, but professionally, in this line of questioning, I often find out important things parents don’t because they are too embarrassed or oblivious to ask–issues that need to be addressed with education on sexual health safety or self-esteem. This comes down to the 1st amendment. If you don’t like the question, don’t answer. I’m sure nobody likes the questions the IRS asks either, but it doesn’t give you the right to scream and threaten the asking professional.

For example, in comparative stats from 26 countries including the U.S. recorded from 1950-93: “The overall firearm-related death rate among U.S. children aged less than 15 years was nearly 12 times higher than among children in the other 25 countries COMBINED.

“The firearm-related homicide rate in the United States was nearly 16 times higher than that in all of the other countries COMBINED. The firearm-related suicide rate was nearly 11 times higher, and the unintentional firearm-related death rate was nine times higher.”

And this isn’t considered a public health issue? Good Lord, then what is?

His article, like just about everything he writes about guns, is so full of factual inaccuracies, deliberately misrepresented statistics and carefully mined data that I can’t even begin to address it all here in Kevin’s comments section.

Nor will I, because this isn’t the place for it, and monkey-poop fights at the zoo are more productive and more entertaining.

But suffice it to say that his “research” is about as reliable as Andrew Wakefield’s. .

The doctor had no business even asking those questions due to a family’s right to privacy for starters. Let alone that a doctors office isn’t the place to push personal beliefs, it should be the patient, the examination, the prescription if applicable, and that’s it.

Kevin

Accidents/deaths related to gun violence are just as much as a public health issue as child car seats, smoking in the home, etc. It is a physician’s duty to inquire about these things! (Go ahead, look up the leading causes of deaths in children, and see how much preventative medicine should play a role.)

ninguem

“…..It is a physician’s duty to inquire about these things!….”

Which means it is a breach of duty NOT to inquire about “such things”.

And that’s precisely the problem.

So take your gun politics and
Get. The. Hell. Out. Of. My. Office.

This applies to both sides. I don’t want some clown trying to impose the conversation when it’s not appropriate. I don’t want some clown prohibiting the conversation when it IS appropriate.

gzuckier

should a physician interviewing a 14 year old inquire whether he/she is sexually active? ask a motorcyclist if he/she wears a helmet? ask if a patient has a smoke detector and CO detector at home? I’d say those are all health related questions. my insurance company seems interested in them, for sure (except for sexual activity, me being above 14), as well as my waist size, BMI, blood pressure, cholesterol, and smoking status. i imagine it’s sheer fear of the gun lobby that keeps that out of bounds.

pj

Interesting how this is now a legal issue- almost all posters here make good points- but the underlying question is, When does the preventive counseling end for physicians?

A Doc should be free to dismiss a patient just as a patient is free to refuse treatment from a Doc, but Docs should also stop pushing ever increasing “quality measures” on their colleagues via board certification and state licensure requirements (mandatory yearly HIV training in some states, etc). That is where part of this mess began.

We are not social workers.

Marc Gorayeb, MD

How absurd. This is a beautiful example of how government solves problems. And some of you would have government run more of your lives and your health care?

Physicians are free to ask any questions they want; patients or parents are free to refuse to answer. If the physician terminates the relationship because he or she does not like the answer, then that may be an ethical breach by the physician, and the state’s board of medicine should investigate. (Yes, the gov’t does have a proper role in our lives). The only other option for the physician is to report the patient or parent to the authorities, assuming it rises to that level. And he or she better have good cause for doing so, because physician-patient confidentiality is paramount.

Termination of care by a physician is a serious matter; and political ideology has no place in the calculus of that decision. And make no mistake: this issue reeks of political ideology, no matter what public health spin people apply to it.

Hexanchus

“Termination of care by a physician is a serious matter; and political ideology has no place in the calculus of that decision. And make no mistake: this issue reeks of political ideology, no matter what public health spin people apply to it.”

Got it in one, Marc!

Jeff Taylor

You might call it spin – but really, as a doctor, would you seriously suggest the many thousands of gun homicides, suicides and accidents a year are not a public health issue? There may well be physicians who would want guns banned or very restricted, but this is not what this is about, is it? It’s about harm reduction, in the same way any home safety issue works, such as window locks in high buildings and locked medicine cabinets.

It seems that the media and public are always talking about prevention. Part of prevention is establishing what risks exist. Taking a detailed history and asking about use of seatbelts while driving, helmets while cycling, smoke detectors and carbon monoxide detectors at home and firearm possession and care and training are part of being complete and thorough. Young people injure themselves and die accidentally more than they die from medical illness. Offering educational written material produced by reputable organizations based on the patient responses is not being judgmental or political.
I treat many elderly individuals who are unable to walk across the room unassisted, sit down in a chair and rise up again without the assistance of an aide. I routinely ask them how they got to the office. Some are cognitively impaired. When they tell me they drove the car to the office , I offer them information on a senior citizen evaluation and driving safety course co-sponsored by our state department of motor vehicles and several reputable senior advocacy organizations. If they own a gun , in the past , I asked if they have taken a state training course available at local shooting ranges , are licensed and offer them printed material on the subject for their review and decision if they are interested. Practicing in Florida I will no longer do that so that I may stay in compliance with a law signed by a governor who was the CEO of Columbia Healthcare when it paid the largest fine for fraud in the history of Medicare and who took the 5th amendment repeatedly when questioned about his role in the fraud.

Hexanchus

“Part of prevention is establishing what risks exist. Taking a detailed history and asking about use of seatbelts while driving, helmets while cycling, smoke detectors and carbon monoxide detectors at home and firearm possession and care and training are part of being complete and thorough.”

OK, I can see your point, but the bottom line is with the ever shorter appointment times, it takes valuable time away from addressing the reason for the patient visit in the first place, unless of course it was to do risk assessment.

If the Dr. wants to ask, fine – but if the patient declines to answer, let it go and move on.

Was the Florida law a knee jerk reaction? Sure it was, but don’t forget it was a physician’s way over the top response of dismissing a patient refusing to answer a question that was not directly related to medical care, that started the whole thing in the first place. The overzealous physicians that are complaining about the law have no one to blame but themselves.

As Marc Gorayeb said, the whole thing reeks of political ideology. Everyone is entitled to their own political beliefs and ideology, but they are not entitled to force them on others. Dr. Mangat speaks of the physician-patient relationship being predicated on trust, but it cuts both ways. How can a patient trust a physician that bases their practice on their own political ideology rather than the wishes and needs of the patient. As I said, it’s fine to have your political beliefs, whatever they may be, but check them at the door when you get to work – they have no place in the exam room.

It’s too bad that it had to come to this, but I don’t see any real problem with the law – except maybe for the self aggrandizing few that want to push their own agenda. There is a provision that allows them to ask if the information is relevant tot the patient’s medical care or safety or safety of others. That pretty much covers it.

gzuckier

the major health risks to the average person these days between 18 and like 35 (or so?) are in fact auto accidents; as well as firearm accidents in certain groups. it would seem scarce time is better spent there, than checking for zebra infestation.

Crazy. Just crazy. FL is #3 in suicide fatalities among states. It also accounts for almost 10% of the malpractice cases in the US.
Let me see. Don’t ask, they don’t have to tell, and if they decide to kill themselves or someone else, you’re responsible.
As someone who practiced emergency psychiatry for 20 years, I would take my criminal chances and protect my malpractice backside.

” not one health care provider, from EMT to ER nurse, to ER doctor to admitting physician to her own primary care doctor asked her these questions. I don’t know why no one else asked – ” First of all, she was completely intoxicated–to the point of requiring admission to a medical facility for her safety (presumably to watch her airway/breathing status). For someone this tanked, there is no benefit from a discussion about why she is drunk. Have you ever tried to have a reasonable exchange with someone that drunk? Not a helpful experience usually. Second, if she was that drunk, are you actually believing her report that ‘no one asked her?’ Who actually knows what the truth is when a drunk presents and later tells their side of the story. May I suggest you obtain the proper medical records from the hospital before you pass on information which is likely flawed (to say the least) and get off your high horse. You’re an allergist and clearly your understanding of what goes on in the hospital is ‘limited’. As an allergist, I’m sure this was the big excitement for the week(aside from the occasional event requiring IM epi), but be sure to be mindful of your words which, unchecked, are likely to prompt critique if they are ill-informed.

Penny

Great, but I did find the gun part a little amusing for a couple of reasons. The first is that most women tend to not like the thought of drying in a gross manner, and that includes gun owners. I myself own one and if I were to commit suicide that’s the last thing I would use, not only because it would leave an ugly gory mess behind but also because it would go against my beliefs in my right to own firearms. Of all people who own guns, the percentage who would actually use them to kill themselves is very small. Sounds like you may have something against guns.

Japan has a suicide rate 19 times as high as our own, and guns there are nearly impossible to find.

So your point is… what, exactly?

Jeff Taylor

I can’t let that ridiculous ‘stat’ pass – Japan’s rate is about twice as high as the US.

And in the US:

‘US residents of all ages and both sexes are more likely to die from suicide when they live in areas where more households contain firearms. A positive and significant association exists between levels of household firearm ownership and rates of firearm and overall suicide; rates of nonfirearm suicide were not associated with levels of household firearm ownership.’

My apologies for the incorrect statistic, Jeff. After reading my comment, I cringed at what I wrote. I honestly have no idea how 19 popped into my head. I have sources close at hand with accurate statistics, and I have no excuse for not consulting them.

Actually Japan’s rate is a bit higher than twice the U.S. rate (26 per 100k vs 11 per 100k), but as Wikipedia notes, Japan also uses a different standard to classify suicide that is somewhat more conservative than that used by the W.H.O. We have to be sure here that we’re actually comparing apples to apples.

As to the rest of your post, I’ll simply say that correlation does not equal causation.

You’ve given your perspective on the issue, now let me give mine:

Last year, 99.96% of the available guns in America killed absolutely no one, and 99.98% of gun owners killed no one.

Given the vast numbers of guns in this country, and the utterly ludicrous notion that laws will curb those numbers in any meaningful way (besides keeping them out of the hands of people who are unlikely to use them in crime anyway), I really fail to see how it’s a major public health issue.

You’d do just as well eradicating the common cold by advising your patients not to sniffle.

Jeff Taylor

There are particular cultural reasons why Japan has a high rate, as you well know.

As for the US, it amazes me that anyone could not see the vastly elevated firearms casualty rate – homicide, intentional injury, suicide, accidents – as a public health issue, especially when you factor in all the costs involved in investigations, healthcare and economic impact on families. This isn’t a matter of proving causation – the stats are not in dispute. Other countries that actually have a higher violent crime rate, such as England, have a tiny gun homicide rate and a low homicide rate overall.

You have to face facts – the US is a major outlier on guns and the health of its citizens. But I don’t understand why people like you rush to pretend otherwise – surely the primacy of gun ownership makes the public health burden a price worth paying?

gzuckier

“Of all people who own guns, the percentage who would actually use them to kill themselves is very small.”
very true; but conversely, of all people who kill themselves, the percentage who use guns to kill themselves is approximately 60%.. Because despite the mess, they are quite effective. this is a problem when coupled with temporary bouts of depression or despair; like when your high school girlfriend breaks up with you and you know there’s a loaded revolver in the sock drawer “for protection”. Kitchen knives, for instance, are much less likely to result in a successful suicide in such a case, as are the contents of the average medicine cabinet. Or, for that matter, rifles, shotguns, or handguns kept locked and unloaded.

My reply is to Jeff Taylor’s last comment. I guess Kevin’s commenting system cuts off replies after a certain number of subheadings.

“… surely the primacy of gun ownership makes the public health burden a price worth paying?”

Let’s be clear – I don’t support HB155. I think that physicians should be able to ask these questions of their patients, and the government has no business interfering in the physician-patient relationship.

My position is that AAP is hardly unbiased on this issue, and pushes a political agenda under the guise of public health. That makes me, and other gun owners, reluctant to answer such questions, and directly led to this overkill piece of legislation.

If doctors want to ask the question, ask. And if you want to educate your patients on safe gun handling and responsible ownership, the educate.

And they have the responsibility to educate themselves about guns and provide useful counseling and resources beyond the standard mantra of “all guns are bad, and all gun ownership is immoral.”

Because then you’re not educating, you’re proselytizing, and if I wanted a sermon, I’d go to someone with some credibility on the issue, like a preacher.